OBJECTIVE:
To estimate the prevalence of severe acute maternal morbitidy and identify its
associated hospital procedures.METHODS: Data from the Hospital Information System, obtained from the
Municipal Secretariat of Health of the city of Juiz de Fora, Southeastern Brazil,
for the years 2006 and 2007, were used. The studied women included those admitted
to the hospital for obstetric procedures (n = 8,620), and whose primary diagnosis
was included within chapter 15: pregnancy, childbirth and puerperium of the
International Classification of Diseases, 10th revision. Codes for routine procedures,
special procedures, and professional acts that fulfilled the World Health Organization's
criteria for severe acute maternal morbidity were identified, as well as other
procedures infrequently employed during pregnancy and the postnatal period.
Logistic regression analysis was employed to identify associations between the
outcome and selected variables.RESULTS: Prevalence of maternal morbidity was 37.8/1000 women, and that
of mortality was 12/100,000 women. Hospitalization for more than 4 days was
13 times more frequent among women with some form of morbidity. After adjustment,
predictors of severe acute maternal morbidity were: duration of hospitalization,
number of hospitalizations, and still births, and the most frequent procedures
and conditions were blood product transfusions (15.7/1,000), "extended stay"
(9.5/1.000) and severe pre-eclampsia/eclampsia (8.2/1,000).CONCLUSIONS: Prevalence of severe acute maternal morbidity was high,
and was related especially to hospitalization and to newborn variables. The
criterion for identifying cases and the use of the National Hospital Information
System proved to be useful for monitoring maternal morbidity and mortality and
increasing our knowledge of its related aspects, contributing to the improvement
of the quality of pregnancy and delivery care.

The maternal mortality
ratio is a sensitive and relevant indicator of the quality of women's health
and health care, and provides a measure of human and social development and
of the quality of life of a population.

Elevated maternal
mortality is associated with other problems such as high maternal morbidity
and perinatal and infant mortality. For every maternal death, several cases
of severe morbidity are registered, many of which lead to permanent sequelae.
Brazilian national estimates indicate that 16 debilitating complications are
registered for every fatal case, with special emphasis on sterility and urinary
incontinence.ª

Conditions leading
to death are in general less frequent, and information on these cases is expected
to have little impact on maternal mortality. Physical and psychological sequelae
of iatrogeny and institutional violence imposed on women during pregnancy and
delivery are difficult to quantify, and are therefore not computed within the
causes of maternal death.

Danel et al2
(2003) reported that, between 1993 and 1997, 43% of pregnant women in the United
States showed some type of morbidity during pregnancy, most of which were preventable.

The concept of
near miss, or severe acute maternal morbidity (SAMM), encompasses procedures
not used in routine delivery care or intercurrences that involve a risk to the
woman's life. According to Souza, et al18 (2006), in a thorough review
of the literature, the a number of criteria are used to define SAMM, including
transfer to intensive care, hysterectomy, and clinical severity criteria (complexity
of management, organ malfunction, and other signs and symptoms). Sheikh et al14
(2006) used loss of blood greater than 1,500 ml as a criterion for SAMM. Other
authors have used mixed criteria.4 Mantel et al7 (1998)
used as criteria emergency hysterectomy; hypovolemia requiring blood transfusion;
pulmonary edema; transfer to intensive care; renal, cerebral, respiratory, metabolic,
hepatic, and coagulatory dysfunction; and anesthesia accidents.

Geller et al4
(2004), using data from patient charts and other sources of information from
a teaching hospital in Chicago, United States, measured three classes of obstetric
indicators: diseases and health conditions, events indicative of disease severity,
and procedures or interventions. These authors detected 11 factors that could
be used in quantitative studies for classification of SAMM cases. Clinical classification
of cases was carried out after analysis of patient charts and considered as
the gold standard. Cases were classified taking into account the sensitivity
and specificity of the criteria employed. While criteria were more specific,
the criteria derived from databases were more sensitive. All cases classified
as SAMM using clinical criteria were identified using the quantitative criteria
(100% sensitivity).

SAMM rates are
used as an indicator of the quality of maternal care in developed countries,
given that maternal deaths are becoming increasingly rare.3

The World Health
Organization (WHO) working group on Maternal Morbidity and Mortality classification
defined a case of SAMM as "a woman who nearly died but survived a complication
that occurred during pregnancy, childbirth or within 42 days of termination
of pregnancy."12 Criteria for identifying SAMM cases considered by
WHO included clinical and laboratory criteria and interventions/procedures.
In an effort to optimize surveillance efforts, this group defined potentially
fatal conditions as hemorrhagic diseases related to pregnancy and delivery,
gestational hypertensive disorders, systemic diseases (pulmonary edema, shock,
septicemia) and procedures indicative of severity (hysterectomy, central venous
access, ICU admission, among others). This list is not definitive, however,
since other non-specified complications may also be severe and lead to death.12

Information systems
available in Brazil, including the System of Hospital Information (SIH-SUS)
of the Unified Health Care System (SUS) and the System of Mortality Information
(SIM), contain a large body of data that could contribute to studies of maternal
mortality and morbidity. SIH-SUS refers only to admissions taken place in hospitals
that see patients through SUS, whereas SIM detects all deaths. Maternal mortality
is underreported in SIM, with variation between the Brazilian regions related
to the active presence of maternal mortality committees and the quality of access
to health services, among other factors.b

A study of the
reliability of SIH-SUS data showed an agreement (kappa) coefficient of 0.98
for pregnancy, delivery, and postnatal care in Maringá, Southern Brazil.8
Veras & Martins19 (1994) found up to 82% agreement between diagnoses
in hospitals in the city of Rio de Janeiro, Southeastern Brazil, and a kappa
of 0.907 when procedures were considered. Bitencourt et al1 (2008)
found kappa values of 0.94 and 0.95 for c-sections and mother's age, respectively,
also in the city of Rio de Janeiro. SIH-SUS is used for the identification of
masked or presumed maternal deaths,5 as a source of information to
estimate neonatal mortality and stillbirth rates,13 and, in association
with SIM, to identify maternal deaths.15

The aim of the
present study was to estimate the prevalence of severe acute maternal morbidity
and to identify hospital procedures associated with this outcome.

METHODS

Data from 2006
and 2007 were provided by the Secretariat of Health of the city of Juiz de Fora,
Southeastern Brazil. SIM data were used to cross-reference the maternal mortality
data obtained from SIH-SUS.

The SIH-SUS database
comprises the following spreadsheets: TB_AIH (which identifies user, hospital,
manager, auditor, primary and secondary diagnoses, procedure, date of admission
and discharge, death); TB_HPE (special procedures); and TB_HSP (codes of professional
services performed and their cost). Common to the three spreadsheets is the
user's hospital admission authorization number (HAA), which can appear multiple
times within the database in case the user has undergone more than one procedure.
The same procedure may be repeated when more than one professional is required
to carry it out.

In the SIH-SUS
database, the initial diagnosis at admission may not be confirmed, and new clinical
conditions of greater severity or complexity may arise. In this case, a change
of procedure is requested, which must be authorized by the general director,
the clinical director, or the hospital management. The new procedure is then
entered in the "Special Procedures" field. When a pregnant woman is admitted
for vaginal delivery and requires a c-section, the c-section is registered as
a special procedure. When more than five special procedures are entered into
a single HAA, a new HAA is generated which bears the same number as the previous
one. Several conditions exist in which a new HAA may be generated, including
transfers from obstetrics to surgery and vice-versa; from obstetrics to obstetrics
in case of two sequential obstetric interventions; from obstetrics to clinics
in the case of delivery or surgical intervention, after the length of stay established
in the spreadsheet is expired. The professional services spreadsheet provides
information on services that are paid for in separate. The special procedure
known as "extended stay" (permanência a maior) is authorized and
recorded in the system when the admission period exceeds twice that predicted
in the procedures chart.c

Certain non-obstetric
procedures are accepted under diagnoses included in Chapter XV of the International
Classification of Diseases, Tenth Revision (ICD-10) for the purpose of payment
of hospital admissions by SUS. Conversely, obstetric procedures accept certain
admission causes that are outside Chapter XV.

Admissions whose
primary diagnosis was included in Chapter XV of ICD-10 and/or admissions in
which obstetric procedures were carried out were retrieved from the TB_AIH spreadsheet.
We used the AIH number to link TB_AIH, TB_HPE, and TB_HSP. We identified the
codes for routine procedures, special procedures, and professional services
that could be classified as SAMM as defined by WHO, as well as of other procedures
or conditions that are not routinely associated with pregnancy, delivery, abortion,
or the postnatal period. All women displaying any of these procedures was considered
as SAMM (Table 1). The primary diagnosis upon admission was
used as one of the criteria for selection, but was not considered in the classification
of cases due to its lack of specificity - approximately 55% of admissions would
be classified as SAMM if these criteria were adopted.

Duplicate AIH entries
were eliminated to yield the total number of women who underwent the selected
procedures. We calculated SAMM occurrence, lethality rate, and proportional
maternal mortality, using as a denominator the number of women with maternal
causes as primary diagnosis/procedure. We use the terms "proportional maternal
mortality" as the number of maternal deaths divided by the number of women admitted
due to maternal causes, and "maternal mortality ratio" in its traditional sense
(number of maternal deaths divided by the number of live births in a given area
and period).

Due to the possibility
of recurrent hospitalizations, total duration of admission was obtained by adding
the durations of all admissions recorded for each woman.

The following variables
were included in the analysis: age, diagnosis upon admission, procedures administered,
duration of admission, number of admissions per woman, newborn remaining hospitalized
after mother's discharge, number of stillbirths, number of newborns who died
before mother's discharge, and transfer of the newborn.

Women with and
without SAMM were compared according to these criteria, and we carried out logistic
regression analysis with variables that were statistically significant in bivariate
analysis.

For analysis of
maternal mortality, we selected deaths with codes pertaining to pregnancy, abortion,
or the postnatal period in SIM. Comparison with SIH-SUS records was manual,
given that the low frequency of such events.

Data analysis was
carried out using SPSS software, version 15.

The research project
was approved by the Research Ethics Committee of the Federal University of Juiz
de Fora (protocol no. 468/2007).

RESULTS

In the studied
period, 8,620 women were hospitalized due to primary diagnoses included in ICD-10
Chapter XV, and/or underwent obstetric procedures. In total, 39,305 professional
services, 15,644 special procedures, and 70,162 routine procedures were administered.
Of all hospitalized women, 326 showed clinical conditions and/or procedures
classified as SAMM, and one woman died. The proportional maternal mortality
in SUS hospitals of Juiz de Fora was 12.0 per 100,000 women, lethality was 3.1
per thousand women, and prevalence of SAMM was 37.8 per thousand women.

Age ranged from
12 to 54 years for women without SAMM and 13 to 54 for those with SAMM. Median
age was 24 and 27 years for these two groups, respectively.

Roughly 13% of
women without SAMM were admitted more than once in the period, whereas this
proportion was 45.7% for SAMM cases. Mean duration of hospitalization was 3.5
and 10.5 days (median three and seven days) for women with and without SAMM,
respectively.

Hospitalization
for more than four days was 13 times more frequent among women with SAMM. SAMM
cases were four times more likely to have multiple admissions than non-SAMM
cases. Prevalence of newborn remaining hospitalized after mother's discharge,
still birth, and newborn death before mother's discharge were higher among SAMM
cases (prevalence ratios of 2.52, 4.86, and 4.41, respectively) (Table
2). Duration of hospitalization, number of admissions, and stillbirth were
predictors of SAMM in logistic regression analysis (p < 0.001) (Table
3).

The most common
procedures/conditions were transfusion of blood products (15.7/1,000), "extended
stay" (9.5/1,000) and severe pre-eclampsia/eclampsia (8.2/1,000) (Table
4).

DISCUSSION

Prevalence of SAMM
(37.8/1,000) was similar to that reported in a systematic review of studies
using different criteria to define SAMM cases.9 Souza et al17
(2010) used admission to intensive care, blood transfusion, eclampsia, and cardiac
and renal complications as markers, arriving at rates of approximately 34.13/1,000
births in Latin-American countries. The estimate for Brazil was 40.67/1,000.
Souza et al (2008),15 using the cause of death registered in SIM
and diagnoses and procedures from SIH-SUS, found rates that ranged from 33 to
42 per 1,000 live births in the capital cities of the Brazilian Southeast Region.
The SAMM ratio was 6.8/1,000 deliveries in a public maternity ward in Campinas,
Southeastern Brazil.16 Martinsd
(2007), using criteria based on clinical conditions and procedures among black
women, found rates of 2.65% in the municipalities of Araucária and 3.3%
in Lapa, both within the metropolitan are of Curitiba, Southern Brazil.

Prevalence of SAMM
according to selected criteria was higher for blood product transfusion (15.7/1,000)
and "extended stay" (9.5/1,000), and, among clinical conditions, for eclampsia
(8.2/1,000). Say et al,11 (2004) found that prevalence varied according
to the criteria used. Rates ranged from 0.8% to 8.2% in studies in which specific
diseases were used, from 0.01% to 2.99% when procedures were the criterion,
and from 0.38% to 1.09% when organ dysfunction was considered. Although the
prevalence ratio was significant for all variables analyzed, multiple regression
analysis showed that hospitalization for longer than four days, more than one
admission during pregnancy, and stillbirths were strongly associated with SAMM.
SAMM is an important factor in premature birth.6,10 In the present
study, we found 2% neonatal deaths and 4% fetal deaths among SAMM cases.

One maternal death
was identified among all hospital admissions, and was classified as SAMM. According
to SIM data, there were six maternal deaths in Juiz de Fora during the studied
period. Cross-referencing the list of deaths in the two systems (SIM and SIH-SUS)
showed that one death took place at home, two were reported in SIH-SUS but did
not include a maternal cause or obstetric procedure upon the second hospitalization
that preceded death. In the two remaining cases, the hospitalization that preceded
death was not included in the SIH-SUS database, even though previous admissions
were included, most likely due to the AIH being presented later or to the occurrence
of a non-SUS admission.

Limitations related
to the use of SIH-SUS are inherent to the purpose for which the system was created:
the payment of health service providers. Since different procedures have different
costs, there may be a propensity for preferential registration of procedures
with higher cost. Another limitation is the lack of adequate training of professionals
that enter the codes for cause of hospitalization, procedures, and professional
services into AIH. Incomplete or missing data for secondary diagnosis, schooling,
antenatal appointments, risk pregnancies, and address makes the full understanding
of cases difficult.

The present method
still shows low sensitivity for capturing cases of maternal death, given that
many of these may occur in the postnatal period or in emergency settings. In
cases of re-admission, the reason for hospitalization does not always refer
to the postnatal state of the mother. A search through patient charts and interviews
with women aimed at confirming cases and understanding factors contributing
to maternal morbidity would be required in order to confirm the criteria for
defining SAMM.

The consistency
of our findings with those reported in the literature shows that cross-referencing
of SIH-SUS spreadsheets has great potential as a tool for identifying SAMM cases.
The system used for identifying cases is feasible and may contribute to surveillance
of maternal morbidity and mortality, furthering our understanding of certain
aspects of these conditions. This in turn may contribute to improvement in the
quality of care provided to women during pregnancy, delivery and the postnatal
period.

Use of SIH-SUS
for capturing cases of SAMM allows for their rapid and timely identification.
Its use, if adopted by managers (as is the case for mandatory notification diseases),
could generate timely and automatic information for surveillance of maternal
morbidity and mortality and evaluation of obstetric care.